Information Collection

State Eligibility Determinations (423.904(b)) and Reporting (423.910(d))

IC 209891 under ICR 202110-0938-012 · OMB 0938-0964.

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Information Collection (IC) Details

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IC Title:	State Eligibility Determinations (423.904(b)) and Reporting (423.910(d))	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 423

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 51	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	600,102	600,102
Annual IC Time Burden (Hours)	13,260	13,260
Annual IC Cost Burden (Dollars)	0	0

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Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.